AMSSM s Universal Application for Fellowship Training

AMSSM s Universal Application for Fellowship Training

AMSSM Fellowship Directors Code of Ethics for the Match 1. Primary Care Sports Medicine fellowship directors will honor and respect other fellowship programs in all written electronic and/or verbal communication with potential candidates. 2. Al l AMSSM affiliated fellowship programs agree to participate in the NRMP Primary Care Sports Medicine Fellowship Match in order to ensure the integrity of the match process. Only programs that adhere to the AMSSM Fellowship Directors Code of Ethics for the Match will: i. be extended the discounted rate of fellowship membership to its fellows, ii. be extended the discounted rate for fellows registration to AMSSM s annual meeting, iii. be listed on AMSSM s website Directory of Fellowships, iv. be allowed to register their fellows for the Fellows Research Workshop, v. be allowed to register their fellows for the Sports Medicine In-training Examination (SM ITE), vi. be allowed to submit fellow cases and research for presentation at AMSSM s annual meeting, vii. be afforded the opportunity for faculty to participate in leadership positions within AMSSM. (Exceptions A newly accredited program will be given a one year grace period to begin its participation in the NRMP Primary Care Sports Medicine Fellowship match. Military sponsored programs are exempt from participating in the match.) 3. Communicating thanks to candidates for coming to a program for an interview is acceptable practice. Applicants may contact the fellowship program with regards to specific questions left unanswered after an interview. A phone call, text message, letter or e-mail to applicants to discuss specific questions not related to the rank order is also appropriate. The fellowship programs may directly contact applicants if they are contacted by the NRMP as an unmatched program. 4. If asked by the applicant to disclose where he/she is ranked, the program director should state that the rank order list is confidential and as a program participating in the NRMP Primary Care Sports Medicine Fellowship Match this information cannot be disclosed. Likewise, program directors may not ask applicants any questions regarding the applicants rank order lists. 5. Possible violations of the AMSSM Fellowship Directors Code of Ethics for the Match will be reviewed by the Fellowship Committee using due process prior to withdrawal of benefits to the program in violation. Refer to www.nrmp.org for the NRMP Statement on Professionalism for further delineation of violations and penalties of the Match as defined by the NMRP. Revision of 1998 AMSSM Fellowship Directors Code of Ethics by Fellowship Committee 7/09

American Medical Society for Sports Medicine UNIVERSAL APPLICATION FOR PRIMARY CARE SPORTS MEDICINE FELLOWSHIP YEAR TO BEGIN FELLOWSHIP 2010 2011 2012 2013 Insert Recent Photo of Applicant Here PERSONAL DATA: Last Name First Name Middle Initial Present Address City State Zip Code Country ( ) ( ) ( ) Home Phone Work Phone Cell Phone Email Address Citizen of U.S. Yes No Social Security Number EDUCATION: College or University City/State Dates Degree College or University City/State Dates Degree College or University City/State Dates Degree Advanced Degree School City/State Dates Degree Advanced Degree School City/State Dates Degree Medical School City/State Dates Degree (MD/DO) GRADUATE MEDICAL EDUCATION: PGY-I HOSPITAL CITY: STATE: DATES (INCLUSIVE) TYPE RESIDENCY HOSPITAL CITY: STATE: DATES (INCLUSIVE) TYPE RESIDENCY HOSPITAL CITY: STATE: DATES (INCLUSIVE) TYPE

US MEDICAL LICENSE EXAMINERS (copy of original required): ** Include all scores whether passing or non-passing. ** Submit FLEX, NBME or COMLEX scores, if applicable. I- date II-date III-date PREVIOUS PRACTICE EXPERIENCE: SPORTS MEDICINE ROTATION (Dates, Type, Location, Instructor): SPORTS MEDICINE COVERAGE (Games, Events, Training Room, Other): SPORTS MEDICINE CONFERENCES: Attended: Presented: PLEASE INCLUDE A COPY OF THE PROGRAM OF ANY LISTED PRESENTATION PUBLICATIONS (author, title, publication, date use additional sheets if necessary): PLEASE INCLUDE A COPY OF THE TITLE PAGE OF ANY LISTED PUBLICATION. ADDITIONAL PERSONAL DATA: 1. Work Experience Prior to Medical Training (Occupation/Title, Dates): 2. Military Status (U.S.A.) (Present Status and Service):

a. Do you hold a reserve Commission? Yes No To begin: for on Branch: Rank: b. Have you served in the military or U.S.P.H.S.? Yes No Have you attended summer training camp? Yes No c. Are you required to attend reserve meetings? Yes No Are you required to attend summer training camp? Yes No d. Do you have a military or U.S.P.H.S. commitment? Yes No To begin: for on 3. Are you certified by the E.C.F.M.G.? Yes No Which qualifying exam taken? a. Dates passed: b. Scores Part I: Part II: c. Certificate Number: d. Certificate valid through what date: 4. If not a U.S. Citizen, will you enter or remain in the U.S. on: a. Exchange Visitor Visa: b. Permanent Visa Number: c. How many years may you remain in the U.S.A.? 5. Conferences attended or presented (other than sports medicine): 6. Honors and Awards: 7. Have you ever been placed on probation, suspended from your job duties, residency, training program, had privileges revoked, or been part of a malpractice complaint? Yes No If YES, please explain below. 8. Are you aware of any limitation which would prevent you from performing the duties of the fellowship for which you are applying?

9. Personal Statement: (please do not exceed 750 words) 10. References and Supporting Documents: *Please ask three physicians who have supervised you in a clinical setting to send letters in support of your application. *Copies of the following documents are requested: medical school diploma, certificate or other validation of all previous training, copy of present state medical licenses, and curriculum vitae. *Please note that individual fellowships may require additional information such as letter of commendation from medical school dean, undergraduate and medical school transcripts, and rotations taken during residency. Contact the individual fellowships you are applying to for further application requirements and deadlines. DO NOT SEND ORIGINAL DOCUMENTS. NO DOCUMENTS WILL BE RETURNED. PHOTOCOPIES OF THIS APPLICATION WILL BE ACCEPTED. HOWEVER THE SIGNATURE ON EACH HARD COPY APPLICATION MUST BE ORIGINAL I certify that the information given or attached is true, accurate and complete. Be advised, any inaccuracies within this application could disqualify your candidacy. Signature: (Signature must be original on hard copies) Date: Check here to verify electronic signature PLEASE SEND ALL APPLICATIONS AND SUPPORTING DOCUMENTS TO THE PRIMARY CARE SPORTS MEDICINE FELLOWSHIPS TO WHICH YOU ARE APPLYING. AMSSM RECOMMENDS A UNIVERSAL DEADLINE OF OCTOBER 1. DO NOT RETURN this application to the American Medical Society for Sports Medicine. I certify that I have read and understand "AMSSM's Fellowship Directors' Code of Ethics for the Match", and will adhere to it throughout the match process. Signature: (Signature must be original on hard copies) Date: Check here to verify electronic signature REMEMBER: AMSSM affiliated fellowships use the National Residency Match Program. Be sure to register for the match through NRMP- www.nrmp.org or call (202) 828-0676.